NURSING PROCESS

Question 1

are subjective or objective data that can be directly observed by the nurse.Ex. Temp-39.6 0C

Answer 1

CUES

Question 2

are the nurse’s interpretation or conclusions made based on the cues.
Ex. Fever

Answer 2

INFERENCES

Question 3

refers to the reasoning process

Answer 3

Diagnosing

Question 4

a statement or conclusions regarding the nature of a phenomenon.

Answer 4

Diagnosis

Question 5

the standardized NANDA names for diagnoses

Answer 5

Diagnostic labels

Question 6

NANDA

Answer 6

North American Nursing Diagnosis Association

Question 7

is a client problem that is present at the time of the nursing assessment

based on the presence of associated signs and symptoms

Answer 7

Actual diagnosis

Question 8

is one in which evidence about a health problem is incomplete or unclear.

Answer 8

Possible Nursing diagnosis

Question 9

is a diagnosis that is associated with cluster of other diagnoses.

Answer 9

Syndrome diagnosis

Question 10

Are words that have been added to some NANDA label to give additional meaning to the diagnostic statement

Answer 10

QUALIFIERS

Question 11

identifies one or more probable causes of the health problem, gives direction to acquire nursing therapy, and enables the nurse to individualized clients card.

Answer 11

causes

Question 12

are cluster of signs and symptoms

Answer 12

Defining Characteristics

Question 13

systematic phase of the nursing process that involves decision making and problem solving.

Answer 13

PLANNING

Question 14

In this phase, the nurse refers to the client’s assessment data and diagnostic statements for :
direction in formulating client goals

Answer 14

PLANNING

Question 15

The product of the planning phase is

Answer 15

Client Care Plan

Question 16

any treatment, based upon clinical judgement and knowledge, that a nurse performs to enhance patient/client outcomes.

Answer 16

NURSING INTERVENTIONS

Question 17

Occurs at the beginning of the shift as the nurse plans the care to be given that day.

Answer 17

Ongoing Planning

Question 18

THIS PLAN Should be initiated as soon as possible after the initial assessment, especially because of the trend toward shorter hospital days.

Answer 18

Initial Planning

Question 19

begins at the first contact of the patient to obtain
information about the client’s ongoing needs

Answer 19

Effective discharge planning

Question 20

a strategy for action that exist in the nurse’s mind

Answer 20

Informal Nursing Care Plan

Question 21

is a written or computerized guide that organizes information about the client’s care.

Answer 21

Formal Nursing Care Plan

Question 22

a formal plan that specifies the nursing care for groups of clients with common needs

Answer 22

Standardize Care Plan

Question 23

is tailored to meet the unique needs of the specific client.

Answer 23

Individualized Care Plan

Question 24

the process of establishing a preferential sequence for addressing nursing diagnoses and interventions.

Answer 24

Setting priorities

Question 25

Setting priorities GROUPING SEQUENCE

Answer 25

Life-threatening problems Health-threatening problems Low priority problems.

Question 26

difference between goal and desired outcome

Answer 26

GOAL (BROAD) : Improved nutritional status DESIRED OUTCOME (SPECIFIC) : Gain 5 lbs by April 25

Question 27

4 components of goal/desired outcome statement

Answer 27

Subject – Verb – Conditions or modifiers – Criterion of desired performance

Question 28

meaning of smart

Answer 28

SPECIFIC MEASURABLE ATTAINABLE REALISTIC TIME – FRAMED

Question 29

are those activities that nurses are licensed to initiate on the basis on their knowledge and skills.

Answer 29

INDEPENDENT INTERVENTIONS

Question 30

Making referrals Ongoing assessment these are what type of interventions

Answer 30

INDEPENDENT INTERVENTIONS

Question 31

Medications Intravenous therapy Diagnostic tests Treatments Diet Activity these are what type of interventions

Answer 31

DEPENDENT INTERVENTIONS

Question 32

are instruction for specific individualized activities the nurse performs to help the client meet established health care goals.

Answer 32

Nursing Orders

Question 33

Includes problem solving, decision making, critical thinking and creativity They are crucial to safe, intelligent care

Answer 33

Cognitive Skills

Question 34

are all activities, verbal and non-verbal, people use when interacting directly with one another.

Answer 34

Interpersonal Skills

Question 35

are “hands-on” skill such as manipulating equipment, giving injections and bandaging, moving, lifting, and repositioning clients

Answer 35

Technical skills

Question 36

Required knowledge and frequently manual dexterity.

Answer 36

Technical skills

Question 37

PROCESS OF IMPLEMENTING

Answer 37

Reassessing the client Determining the nurse’s need for assistance Implementing the nursing interventions Supervising delegated care Documenting nursing activities

Question 38

is to judge or to appraise

Answer 38

evaluate

Question 39

is a planned, ongoing, purposeful activity in which clients and health care professionals determine The client’s progress toward achievement of goal/outcomes Effectiveness of the nursing care plan

Answer 39

EVALUATING